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Toronto Star
Klein moves to gut medicare
Mar. 1, 2006. 01:00 AM
THOMAS WALKOM

Ralph Klein has finally done it. The Alberta premier took direct aim at
medicare yesterday with a plan that would formally legalize two-tier
medicine in his province.

Klein's been at this for years. For his own, never-explained reasons, he
has long had it in for medicare.

The only thing that's stopped him is the fact that Albertans, like most
Canadians, value the country's publicly funded health insurance scheme.

Now in his final term as premier, he has finally delivered the
long-promised poisoned apple.

Titled simply Health Policy Framework, the 18-page white paper released
yesterday by Alberta Health Minister Iris Evans lays out a plan that, if
implemented, would undermine universal medicare in the province and cause
repercussions throughout the country.

It would do so by the simple expedient of allowing physicians to practise
both inside and outside medicare.

Currently, every Canadian province with the exception of Newfoundland bars
doctors who are part of the public medicare plan from offering the same
so-called medically necessary services privately.

The reason is straightforward. The Canada Health Act, the federal law
governing medicare, requires medically necessary services in participating
provinces be offered equally and without extra charge to all citizens.

Most provinces decided that the simplest way to ensure this outcome was to
give physicians a choice. They wouldn't be compelled to join medicare;
indeed, they could charge patients privately to set bones or remove their
spleens.

But if a doctor stayed out of medicare in some cases, he or she had to stay
out in all.

For most doctors, this creates an important financial incentive to stick
with medicare. Most figure they can't make a living operating entirely
outside the public system. (In Ontario, the current Liberal government
changed the law two years ago to require all physicians to operate inside
medicare).

Even in Quebec, which has one of the most highly developed private systems
in Canada, fewer than 100 physicians have opted out.

In Alberta, only one general practitioner has chosen to operate outside of
medicare.

But Alberta's government would alter this balance significantly. In its
white paper, the government says it wants to let the province's physicians
operate both inside and outside of the public system insofar as
"non-emergency services" are involved.

The aim, the paper says, is to "let individuals pay privately for faster
access."

Practically speaking, that means doctors would be able to offer, say,
high-priced hip replacement surgery to well-heeled patients on Tuesdays and
then follow with medicare-financed hip replacements on Thursdays.

The problem, as University of Toronto law professor Colleen Flood points
out, is that at any given time there are only a limited number of doctors.

If physicians are busy with their private-pay patients two or three days a
week, they don't have as much time for their medicare ones. And that, in
turn, means that waiting times within the public system will rise.

"Countries that allow the free movement of physicians between the private
and public systems, like the United Kingdom, New Zealand, Australia, have
big problems with waiting lists," Flood said yesterday. "So why would this
help?"

She says the Alberta plan would be in "clear contradiction" of the Canada
Health Act, which newly minted Prime Minister Stephen Harper has vowed to
uphold.

Curiously, the proposal to gut medicare is in the midst of a paper that is
otherwise unremarkable.

Like every other province, Alberta says it wants to figure out ways to
encourage teamwork, expand efficiency and make the public system work
better.

Michael Rachlis, a Toronto physician and consultant, says that in some
areas Alberta under Klein has made path-breaking health reforms —
particularly in the use of specialized public clinics to perform elective
surgery.

"In some ways, Alberta's public system has become the envy of Canadians,"
said Rachlis. "And yet Klein still continues to talk about this (hammering
medicare).

"It's eerie. Some of this (white paper) makes a great deal of sense. But
other parts read as if they are cut and pasted from someone's ideological
manifesto."

Certainly, Klein's proposals do promise to rekindle the great medicare
debate.

From British Columbia, Brian Day, an orthopedic surgeon and outspoken
proponent of two-tier medicine who is expected to become the next head of
the Canadian Medical Association, welcomed the white paper.

"This has the potential to offer (shorter waiting times) to Canadians," Day
said.

"The private sector is not a panacea. But I think that even if only 1 or 2
per cent of the system is privatized, the competition will make the public
system do better."

Ontario Health Minister George Smitherman disagreed.

"Where people can pay more to receive more timely access, this is
fundamentally at odds with the principles of a public health-care system,"
he told the Star's Rob Ferguson.
Additional articles by Thomas Walkom